You Never Know

We’re called for chest pain at the court house. We question whether it is a case of “Jailitis.” We find the patient sitting in the lobby on a bench surrounded by marshals and firefighters. It is a young man – twenty-five. My first reaction is he is a prisoner, but then I realize he is wearing street clothes. We hear the story. He was walking down the street when suddenly he felt an intense tearing sensation in his chest going into his back. He is a heart transplant patient. A firefighter hands me a paper with medical history on it. It is a typed report from a hospital saying the patient has a diagnosed Aortic dissection.

“Aortic dissection is a condition in which there is bleeding into and along the wall of the aorta (the major artery from the heart). This condition may also involve abnormal widening or ballooning of the aorta (aneurysm).”

While the man looks okay, he also seems extremely tense. I would be too with that history. An aortic dissection rips open and the person bleeds out in a minute. One moment awake, the next dead.

I nod to my preceptor as I lower the stretcher. Let’s just get him on the stretcher and on the way to the hospital. His pressure is okay. When my preceptee says he is going to start a line, the man says he has no veins, the hospital has to use central lines so we shouldn’t bother. We are already enroute to the hospital. I hand the CMED radio to my preceptee. He stutters some with the patch. The patient snaps at him when he says stomach pain. “It’s not stomach pain, it’s chest pain, pain into my back.”

When I ask for the meds he’s on, he starts rattling off a list. I ask him to repeat one; he says the name again, but with thick frustration. He glances back to try to look ahead. “Are we at the hospital yet? How far is it?”

“Just up the road.”

When we finally approach the hospital, the man, seeing the ambulances out the side window, says urgently, “You just went past the ER!”

“No, listen, I know you are concerned, but we know where we’re going. It’s a one way drive.”

He apologizes.

“We’ll get you good care.”

In the ER, I tell the triage nurse the man has a possible AAA. “No! It’s not possible, it’s been diagnosed,” he snaps. “I have it.”

“Okay,” I say. “We’re getting you a room now.”

He looks like he is about to snap as we wait for the triage nurse to give us a room assignment. His hand keeps tapping his leg. “Man, I can feel it pulsing!” he shouts.


Later I see the nurse who was taking care of the man. I ask how he made out, curious whether or not he was rushed to surgery. I imagine his AAA rupturing in the elevator and him bleeding out before the doors can open. The nurse says he was very squirelly with the doctors. They called the other hospital in town and found out he had been there the night before. They felt he was drug seeking. He ended up walking out of the ED and taking a cab to a third hospital.


  • Anonymous says:

    This reminds me of a situation I encountered the other day — a woman ran off the road in her car. Bystandards called it in as an accident. PD arrived on scene and seemed to think that she had an altered LOC, maybe due to diabetes. She was pretty open about her medical history.Mid 30s, with a variety of heart problems. She was taking some anti-arrythmic meds and some anti-psychotic meds usually prescribed for schizophrenia. The medic was leery of her story, thinking it was maybe a syncopal episode or panic attack. But there was something more. When he learned of her psych meds, the skepticism increased.But I’m torn. I think something was genuinely amiss with this woman, but exacerbated by her mental disorders. It’s a struggle for me since I know that people with a psych history can have legitimate medical concerns and are often not taken very seriously by people in emergency medicine. Statistically, I think this group is more likely to have spurious complaints, but that is also not the norm and definately does not fit into the “treat for the worst” mantra. I don’t like to be lied to or deceived by drug seekers. But I also have some huge moral concerns about the mentally ill not being treated in the same fashion as someone with no psych history that has an identical complaint.When I read your post, I started to wonder if my compassion wasn’t in vain. I’d almost rather not know that I was lied to since it taints my view of people. Part of me really wants to know outcomes, but there’s a danger in that too.

  • Anonymous says:

    funny – in our system we call it incarceritis. 🙂

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